Download DRG 127— Congestive Heart Failure ICD-9-CM Coding

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DRG 127— Congestive Heart Failure
ICD-9-CM Coding Guidelines
The below listed congestive heart failure (CHF) guidelines are not inclusive. The coder should refer
to the applicable Coding Clinic guidelines for additional information. The Centers for Medicare &
Medicaid Services considers Coding Clinic, published by the American Hospital Association, to be the
official source for coding guidelines. Hospitals should follow the Coding Clinic guidelines to assure
accuracy in ICD-9-CM coding and DRG assignment.
Definition of Principal Diagnosis
The principal diagnosis is that condition established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for care.
Two or more diagnoses may equally meet the definition for principal diagnosis as determined
by the circumstances of admission, diagnostic work-up and/or therapy provided. Be aware that
there is a difference between admitting a patient to treat two conditions and two conditions being
present at the time of admission. The principal diagnosis is always the reason for admission.
Documentation to Support CHF
When reviewing a record with the diagnosis of CHF, identify the documentation that
substantiates CHF. This may include:
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The results of the chest X-ray
Presence of dyspnea with mild exercise
Orthopnea
Paroxysmal nocturnal dyspnea
Fatigue with exertion
Jugular vein distention
Ankle swelling
Pitting edema of the lower extremities
DRG 127
Coding Guidelines
Acute and chronic heart failure
Acute and chronic heart failure is assigned code 428.9. Be sure this is not congestive heart
failure, 428.0. (See Coding Clinic, November-December 1985, page 14.)
Acute pulmonary edema/CHF
Acute pulmonary edema of cardiac origin is a manifestation of heart failure, category 428. (See
Coding Clinic, third quarter 1988, page 3.) In addition, the excludes note for acute pulmonary
edema, 518.4, in ICD-9-CM includes acute pulmonary edema with mention of heart disease or
failure, 428.1.
Combined systolic and diastolic CHF
A diagnosis of acute combined systolic and diastolic congestive heart failure in a patient with
a known history of CHF is assigned code 428.43, combined systolic and diastolic heart failure,
acute on chronic, with an additional code of 428.0, congestive heart failure, unspecified. (See
Coding Clinic, fourth quarter 2002, pages 52 and 53.)
Revised: March 2006
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Congestive cardiomyopathy/CHF
The symptoms of CHF and congestive cardiomyopathy are very similar. Cardiomyopathy is a
heart muscle disease/disorder. CHF is a manifestation of an underlying cardiac condition which
demonstrates inadequate cardiac output. (See Coding Clinic, September-October 1985, page 15.)
When both congestive (dilated) cardiomyopathy and CHF are present the treatment primarily
involves management of CHF in most cases. Therefore, CHF is sequenced as the principal
diagnosis. (See Coding Clinic, second quarter 1990, page 19.)
Fluid overload/CHF
A chronic renal failure patient who is regularly on dialysis is admitted with volume overload
due to salt and fluid levels and the patient’s condition progresses to CHF. CHF is the principal
diagnosis. Fluid overload is integral to CHF and should not be assigned a code. (See Coding
Clinic, third quarter 1996, page 9.)
A chronic renal failure patient is admitted with fluid overload and CHF due to noncompliance
with dialysis. The patient is treated with dialysis. The principal diagnosis is CHF, 428.0. Fluid
overload is integral to CHF and should not be assigned a code. (See Coding Clinic, second
quarter 2001, page 13.)
Heart failure
For information on the various descriptions of heart failure see Coding Clinic, fourth quarter
2002, pages 49-53, and Coding Clinic, second quarter 1990, pages 16-18.
Category 428, heart failure, has expanded codes effective October 1, 2002, so that systolic heart
failure, diastolic heart failure or a combination have separate codes. These new codes also have
fifth digits to indicate whether the condition is unspecified, acute, chronic or acute on chronic.
(See Coding Clinic, fourth quarter 2002, pages 49-53.)
Congestive heart failure (CHF) is not an inherent component of systolic or diastolic heart failure.
Assign a code for systolic and/or diastolic heart failure, plus a code for CHF when they are
present. (See Coding Clinic, fourth quarter 2004, page 140.)
Hypertension/CHF
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If a patient has CHF and hypertension, the physician must state that CHF is due to hypertension
before it is coded to hypertensive heart disease with CHF, 402.91. (See Coding Clinic, second
quarter 1989, page 12.) This information was superceded as of October 1, 2002, when two codes
became necessary to code hypertensive heart disease with CHF, 402.91, hypertensive heart disease
with unspecified heart failure, and 428.0, congestive heart failure. If heart failure is known to be
systolic, 428.20-428.23, diastolic, 428.30-428.33, or combined systolic and diastolic, 428.40-428.43,
another code should be assigned. (See Coding Clinic, fourth quarter 2002, pages 49-53.)
CHF due to diastolic dysfunction due to hypertension is assigned code 402.91. If only a diagnosis
of diastolic dysfunction is present, assign code 429.9. (See Coding Clinic, first quarter 1993, pages
19 and 20.) This information was superseded as of October 1, 2002, when three codes became
necessary to code CHF due to diastolic dysfunction due to hypertension, hypertensive heart
disease, unspecified with heart failure, 402.91, diastolic heart failure, unspecified, 428.30 and
congestive heart failure, unspecified, 428.0. (See Coding Clinic, fourth quarter 2002, page 52.)
Hypertensive cardiomyopathy and CHF is assigned code 402.91, hypertensive heart disease,
unspecified, with CHF, plus 425.8, cardiomyopathy in other diseases classified elsewhere. (See
Coding Clinic, second quarter 1993, page 9.) As of October 1, 2002, hypertensive cardiomyopathy
and CHF requires three codes; 402.91, hypertensive heart disease, unspecified with heart failure,
428.0, congestive heart failure, unspecified and 425.8, cardiomyopathy in other diseases classified
elsewhere. (See Coding Clinic, fourth quarter 2002, pages 50 and 51.)
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Revised: March 2006
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Effective October 1, 2002, category 402, hypertensive heart disease, had the narrative description
changed from “with or without congestive heart failure” to “with or without heart failure.”
Therefore, an additional code is required to specify the type of heart failure; 428.0, 428.20-428.23,
428.30-33, 428.40-428.42.
Infant (28 days old or less)/CHF
When the index does not provide a specific code for a perinatal condition, assign code 779.89,
other specified conditions originating in the perinatal period, followed by the code from another
chapter that specifies the condition. CHF in an infant 28 days old or less is assigned code 779.88
and 428.0, congestive heart failure, unspecified. (See the Official Newborn (Perinatal) Guidelines
for Coding And Reporting and Coding Clinic, first quarter 2005, page 9.)
Nesiritide, injection of
Nesiritide is the generic name for recombinant human B-type natriuretic peptide. This drug
represents a new class of agents. It is used for treating acutely decompensated CHF with dyspnea
at rest or with minimal activity. Effective October 1, 2002, a new code was created for injection of
Nesiritide, 00.13, injection or infusion of nesiritide. (See Coding Clinic, fourth quarter 2002, page 94.)
Pleural effusion/CHF
Pleural effusion is never the principal diagnosis when it is associated with CHF. When pleural
effusion is treated through more aggressive treatment of the underlying CHF, pleural effusion
should not be coded as an additional diagnosis. Pleural effusion can be coded as an additional
diagnosis when special x-rays are required or diagnostic or therapeutic thoracentesis or chest
tube drainage is performed. (See Coding Clinic, third quarter 1991, pages 19 and 20.)
Respiratory failure/CHF
When a patient is admitted in respiratory failure due to/associated with CHF, CHF was the principal
diagnosis until discharges of April 20, 2005, when the respiratory failure guidelines were revised.
A patient with congestive heart failure (CHF) is admitted to the hospital for acute respiratory
failure. The principal diagnosis is acute respiratory failure, 518.81, and the secondary diagnosis
is CHF, 428.0. The principal diagnosis depends on the reason for admission. Query the physician
if the documentation is unclear. (See Coding Clinic, first quarter 2005, page 5, and Coding Clinic,
second quarter 1991, pages 3 and 4.)
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Rheumatic heart disease/CHF
A diagnosis of heart failure in a patient with rheumatic heart disease is assigned code 398.81,
rheumatic heart failure, unless the physician specifies a different cause. (See Coding Clinic,
second quarter 2005, pages 14 and 15.)
Rheumatic mitral and aortic valve insufficiency/CHF
The presence of CHF with rheumatic mitral and aortic valve insufficiency is assigned code
398.91, rheumatic heart failure (congestive) and 396.3, mitral valve insufficiency and aortic valve
insufficiency. (See Coding Clinic, first quarter 1995, page 6.)
Secondary diagnosis of CHF
Prior to July 1, 2000, when a patient had a history of congestive heart failure (CHF) and was
continued on medications for CHF during a hospitalization, CHF was coded and sequenced
as a secondary diagnosis. (See Coding Clinic, third quarter 1991, page 18.) After July 1, 2000,
treatment was no longer required for CHF. CHF is a chronic condition that should be coded even
in the absence of active intervention. CHF, like COPD, would tend to always impact care and/or
treatment. (See Coding Clinic, second quarter 2000, pages 20 and 21.)
Revised: March 2006
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